Provider Demographics
NPI:1598006728
Name:CRISOSTO, SONJA CHARLENE (LCSW)
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:CHARLENE
Last Name:CRISOSTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7509 NE PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6274
Mailing Address - Country:US
Mailing Address - Phone:971-212-9843
Mailing Address - Fax:
Practice Address - Street 1:4224 NE HALSEY ST STE 335
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1568
Practice Address - Country:US
Practice Address - Phone:503-922-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
ORL112361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP4723Medicaid